Permit u CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2011 -00187
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/14/2011
Parcel: 2S113AD01700
Jurisdiction: Tigard
Site address: 16850 SW 72ND AVE
Project: Bridal Exclusive Subdivision: ROSEWOOD ACRE TRACTS Lot: 30
Project Description: Capping (9) fixtures and installing two bathrooms for bridal shop.
Contractor: KEEFER PLUMBING INC Owner: BRIDGEPORT LAND LLC
PO BOX 562 3939 NW ST HELENS RD
HILLSBORO, OR 97123 PORTLAND, OR 97210
PHONE: 503 - 750 -5211 PHONE:
FAX:
FEES
Quantity Description Date Amount
g ea Fixture /Sewer Cap 06/14/2011 $225.18
Specifics: 2 ea Lavatories 06/14/2011 $50.04
2 ea Water Closet 06/14/2011 $50.04
Type of Use: COM 1 ea Water Heater 06/14/2011 $37.52
Class of Work: ALT 1 12% State Surcharge - 06/14/2011 $43.53
Type of Const: Plumbing
Occupancy Grp:
Stories:
Total $406.31
•
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance • ' . ork is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utilit otification - • er. Tho - rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules
or . irect questions to OU C by allin• 50 32.1987 or 1.800.332.2344.
Is. ued By: 1 . / " / , / Permittee Signature:
k h / 46., / I gik
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Plumbing Permit Applicati
Building Fixtures FOIZ OFFict: I SE O\I.\
City of Tigard JUN 14 2011 Received /
Le
_ N // , Permit No.: 1 (4/Ael1.. eicyg 7
IN 8 • 13125 SW Hall Blvd„ Tigard, OR 97223 Date /By:
Phone: 503.718.2439 Fax: 503.
VITIO TIGARD Plan Review Other Permit No.:
T I G A R D Inspection Line: 503.639.4175 BUILDING DIVISIO Ready/By: Juris: g
Internet: www.tigard- or.gov Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Descri • tion • . Ea. Total
F Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70
El 1- and 2- family dwelling El Commercial/industrial SFR (2) bath 437.78
SFR (3) bath 500.32
❑ Accessory building ❑ Multi- family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other:
Fire sprinkler sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: / /; g'o S j 7 2-A) Q ` I Catch basin or area drain 18.76
City/State /ZIP: `6' (�� *-� /T Drywell, leach line, or trench drain 18.76
\ r� 7 t� V - l (��- Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: 01 Project name: Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map /parcel no.: a I j 34-0- Q / 700 Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
1 0 5 t 1( 2_ ti: i-tkveo9 sPf,v Dishwasher 25.02
jr A i k.. S r. Drinking fountain ■ 25.02
Q
Ejectors /sump 25.02
❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12.51 �!
Name: Fixture /sewer cap 25.02 . /
Floor drain/floor sink/hub 25.02
Address:
Garbage disposal 25.02
City /State /ZIP: Hose bib 25.02
Phone: ( ) Fax: ( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Business name:
Medical gas (value: $ ) Page 2
Primer 12.51
Contact name:
Roof drain (commercial) 12.51
Address: Sink/basin/lavatory '. 25.02 50 A
City /State /ZIP: Solar units (potable water) 62.54
Phone: ( ) Fax: : ( ) Tub /shower /shower pan 12.51
E -mail: Urinal 25.02
Water closet 5- 25.02 O.
CONTRACTOR
Water heater .' 37.52 7. 5 0
Business name: �142 0 W4 10 f 1ft Water piping/DWV -- 56.29
Address: 11. r I d ^ • - z -J Other: 25.02
City/State /ZIP: (\ s , t 7 1 3 Subtotal 63. _ 7
Phone: (5 6 2 cr _/ O Fax: ( 3) � ` Minimum permit fee: $72.50
CCB Lic.: • C • C7 Y ( y Plumbing Lic. no.: l '.-_ - Plan review (25% of permit fee)
State surcharge (12% of permit fee)
Authorized signature: 7// tl TOTAL PERMIT FEE a ,
Print nam This permit �� K___ t� Date: 6,(/ Lt�n � ermit alication expires if a permit is not obtained within 180 days
after it has been accepted as complete.
!
T � *Fee methodology set by Tri-County Building Industry Service Board.
I:\Building\Permits\PLMU- PermitApp.doc 10/01/09 440- 4616T(10 /02/COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee:
Footing drain - 1' 100' 50.03 0 to 2,000 $121.90
Footing drain - each additional 100' 37.52 2,001 to 3,600 $169.69
3,601 to 7,200 $233.20
Sewer - 1st 100' 62.54
7,201 and greater $327.54
Sewer - each additional 100' 37.52
Water Service - 1st 100' 62.54 Medical Gas Systems:
Water Service - each additional 100' 37.52
Valuation: Permit Fee:
Storm & Rain Drain - 1st 100' 62.54 $1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 37.52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for
Other Inspections or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to
P and including $10,000.00.
Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof, to
(minimum charge - 1/2 hour) and including $25,000.00.
Inspections outside of normal business 90.00/hr $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
hours (minimum charge - 2 hours) each additional $100.00 or fraction thereof, to
Reinspection Fees 90.00/hr and including $50,000.00.
Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
(minimum charge 1/2 hour) each additional $100.00 or fraction thereof.
Subtotal:
Commercial Fixture Work:
Are you capping, adding or replacing fixtures? If "yes ",
please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees
Quantity by Fixture Type Plan Review for Plumbing Installations
Fixture Type for Replace/ Plan review is required for any of the following. Performed: Capped Added Relocate
Please check all that apply.
y g
Baptistry/Font
Bath Tub /Shower ❑ Any new commercial building with water service 2" and
Jacuzzi/Whirlpool greater, except systems designed and stamped by licensed
Car Wash -Each Stall engineer.
-Drive Thru ❑ New exterior plumbing site utilities for any complex structure
Cuspidor/Water Aspirator as defined in OAR918- 780 -0040.
Dishwasher - Commercial ❑ Medical gas and vacuum systems for health care facilities.
- Domestic ❑ Any multipurpose fire sprinkler system.
Drinking Fountain Z ❑ Any complex structure as defined in OAR918- 780 -0040.
Eye Wash
Floor Drain/sink - 2" Submit 2 sets of plans with any of the above.
-3"
4 " Isometric or Riser Diagram
Car Wash Drain ❑ Isometric or riser required ram is uired for new buildings
Garbage - Domestic - non - food g q g
Disposal - Domestic - food related that meet the qualifications above.
- Commercial -food related
- Industrial -food related
Ice Mach./Refrig. Drains
Oil Separator (Gas Station) Comments regarding fixture work:
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink/Lav - Non -food related ., 'Z
- Bradley
- Commercial-food related
- Service
Swimming Pool Filter *Note: If the fixture work under this permit results in an
Washer - Clothes
Water Extractor increase of sewer EDUs, a sewer permit will be issued and
Water Closet Toilet � fees assessed for the sewer increase must be paid before the
Urinal plumbing permit can be issued.
Other Fixtures:
I:\Building\Permits\PLMF - PermitApp.doc 02/24/2011 2
Accumulative Sewer Tally Parcel # 2S1 1 3ADO1 700
Tenant Name: Bridal Exclusive This SWR4 N/A
Site Address: 16850 SW 72nd Ave This PLMt 2011 -00187
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s count value #s values
Baptisery/Font 4 0 0 0 0 0
Bath - Tub /Shower 4 0 0 0 0 0
- Jacuzzi /Whirlpool 4 0 0 0 0 0
Car Wash - Each Stall 6 0 0 0 0 0
- Drive through 16 0 0 0 0 0
Cuspidor /Water Aspirator 1 0 0 0 0 0
Dishwasher - Commercial 4 0 0 0 0 0
- Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 2 2 0 -2 -2
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink - 2 inch 2 0 2 4 0 -2 -4
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Drn 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 0 0 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 HP) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Sep (Gas Station) 6 0 0 0 0 0
Rec. Vehicle Dump station 16 0 0 0 0 0
Shower - Gang (per head) 1 0 0 0 0 0
- Stall 2 0 0 0 0 0
Sink - Bar /Lavatory 2 0 3 6 2 4 -1 -2
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 0 0 0
- Service 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 2 12 2 12 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 9 24 4 16 _ -5 -8
Current Fixture Value -8 divided by 16 = -0.5 Current EDU 1 EDU = $ 4,100
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change -8 divided by 16 = -0.5 over (under) $ (2,050.00)
/� A Enter EDU Change Here -0.5
Notes: , .#t 7) l 7 sk `
Authorized Name /Signature: Debbie Adamski Date: 6/14/2011
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
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